Who's at fault when plastic surgery goes wrong?

In her heyday half a century ago, Kim Novak was one of Hollywood’s most stunning female stars, her acting legacy cemented by a leading role in Vertigo, the Alfred Hitchcock classic.

Her reemergence in the public eye during last Sunday’s Oscar telecast was not quite so triumphant. Many viewers were stunned by the 81-year-old’s physician-altered face, the skin pulled tight like a woman decades younger, her mouth stretched and puckered.

The slew of social-media comments that ensued — Donald Trump tweeted Ms. Novak should fire her cosmetic surgeon — were swiftly condemned as a gratuitous assault on an elderly woman.

Yet her appearance underlines a little-discussed aspect of the booming cosmetic surgery business: the nips, tucks, breast jobs, liposuctions and other operations that go badly wrong, at least in the patient’s eyes.

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Canadian courts see a steady stream of malpractice lawsuits launched by patients alleging an array of surgical failures, from nipples that don’t line up, to breasts that have been “deformed” and eyebrows that simply don’t work.

“There’s a lot of unhappy clients out there,” said Jillian Evans, a Toronto lawyer who has represented many of them.

The lawsuits represent the most serious complaints, but underscore cosmetic surgery’s unique place in the practice of medicine. Barring medical complications, success is measured, not by the physician’s ability to treat disease or fix injury, but by a purely esthetic – and sometimes subjective – scale.

“We’re not saying, ‘Now you can walk,’ or ‘Now you can breath,’ ” said Dr. Tom Buonassisi, a Vancouver specialist in face surgery.

“It’s more like ‘Has this improved your appearance in a way you wanted, or has it just changed your appearance in a way that you didn’t really expect or want?’ Change is not necessarily good.”

Surgeons say that means they have to manage patients’ frequently lofty expectations, grapple with requests for overly aggressive treatment and make clear perfect results can not always be guaranteed.

As it turns out, elderly people like Ms. Novak, eager to gain a younger glow, are a burgeoning market for cosmetic specialists; Dr. Buonassisi says they form a significant chunk of his practice.

Most simply want a visual freshening, and he recommends the goal to be appearing healthier and more “vibrant,” but not overtly younger.

Dr Nick Carr, another Vancouver surgeon and vice-president of the Canadian Society for Aesthetic Plastic Surgery, said he tells patients people should not even notice they had gone under the knife.

Some senior citizens, though, expect much more. The 70-year-old who asks to look like she did when 30 or 40 is not uncommon, said Dr. Carr.

Even the most skilled surgeon, of course, cannot turn back time. An elderly person who has one part of their anatomy rendered much younger-looking can seem just not right.

“They have a very rejuvenated single feature,” said Dr. Buonassisi, “but they are still hunched over, they still have grey hair or brittle hair or all the other things associated with aging.”

They have a very rejuvenated single feature, but they are still hunched over, they still have grey hair or brittle hair or all the other things associated with aging

He pointed to one picture of Ms. Novak at the Oscars where her youthful-seeming face is belied by the wrinkled, frail hands of an octogenarian.

Still, not all poor outcomes of cosmetic surgery can be attributed to unreasonable patient demands, or the subjectivity of beauty.

Many of the patients who go to the length of filing a lawsuit against their surgeon have clearly been disfigured by the procedure.

Alan Rachlin, a Toronto lawyer, said he has one case now where the surgeon created the pocket for a breast implant below the skin “crease” that essentially holds breasts in place, so “the implants keep falling down and trying to get to the woman’s belly button.”

Court rulings from the last few years reveal a variety of disgruntled patients:

A Filipino-Canadian woman won $155,000 in damages for breast-augmentation surgery that left her breasts “highly, visibly asymmetrical,” with nipples that faced in different directions and had lost all erotic sensitivity.

A B.C. woman complained she was unable to wrinkle the left side of her forehead and had noticeably uneven eyebrows after a brow lift.

An Ontario patient sued after another surgeon confirmed an operation to augment her breasts had in fact “deformed” them.

A B.C. woman sued over lip surgery that failed to change the downturn in her mouth, but left it so tight, it was difficult to “smile, talk and eat.”

A Toronto exotic dancer went to court claiming disfiguring liposuction had ended her career.

Problems sometimes crop up, not necessarily because of incompetence, but out of competitiveness, said Ms. Evans.

“It’s financially driven: it’s a private, profitable area of surgery,” she said.

“You always want to be on the cutting edge of the industry, and I think that leads to, perhaps, trying out new techniques a bit more aggressively than in other surgical fields.”

A minority of them can claim physical appearance affects their ability to earn an income, inflating the potential compensation.

Sloan Mandel, another Toronto malpractice lawyer, said he once represented a stripper whose breasts had been disfigured by a cosmetic surgeon. Mr. Rachlin said he had a client who was a TV personality and felt a badly done eye lift “affected her ability to appear on camera.”

Without such career implications, though, damages are usually limited to well under $100,000 – typically for pain and suffering or the cost of revision surgery. That makes the economics iffy when there is a risk of losing and having to pay the other side’s costs.

Mr. Mandel had already had to turn down two patients eager to sue the day he was contacted by the [itals]National Post.[enditals]

What is more, plaintiffs have to prove the surgeon worked below the standards of the profession in producing the seemingly botched results, or failed to gain informed consent by outlining the risks.

In Ontario, cosmetic surgeons usually refuse to testify against one of their colleagues in the relatively small specialty, said Mr. Rachlin.

The most tenuous cases to pursue legally may involve those patients who are desperately unhappy with results that, to others, seem not so bad.

Or the outcome may simply fall short of high expectations, perhaps fueled by clinic marketing replete with enticing images of lithe bodies and comely faces.

“They thought they were going to look like Jennifer Aniston and they come out looking somewhat less than they hoped to achieve,” said Mr. Mandel.

“If you’re sold a Maserati, you expect to drive home a Maserati, and sometimes they come out with the Toyota.”

From the surgeon’s perspective, the results of some operations can simply not be guaranteed. Different people have different physical attributes so, for instance, pulling tight the skin during a face lift will have varying results depending on the elasticity of an individual’s skin, said Dr. Buonassisi.

As for Ms. Novak, it appears likely she had “fat transfers,” where lipids are sucked out of one part of the body and injected into the face, the idea being to fill out a visage that has begun to sink in with age, said Dr. Buonassisi.

If you’re sold a Maserati, you expect to drive home a Maserati, and sometimes they come out with the Toyota

But some patients ask – and some surgeons agree — to have excessive amounts of fat transferred in one treatment, a “barbaric” practice that can create an unpleasant puffiness, he added.

The former actress’s odd appearance, and the similarly worked-on looks of some other older actresses at the Oscars may also represent a cultural gulf. Canadian women tend to favour the subtle improvements that imbue youthful vigour but do not transform, whereas in Hollywood more dramatic results may well be fashionable, said both surgeons.

Ms. Novak’s physician, rather than being fired, “is probably extremely busy right now with people who want to look like her,” speculated Dr. Buonassisi.

“If you live in one of these rarefied environments and you see celebrities all the time and the norm amongst all your friends is that they do look altered, maybe the esthetic standards do change,” echoed Dr. Carr.

“If … all your friends have big lips, you start at some point to think ‘That’s great, that’s what I want, too.’ ”

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